SA surgery and nasal disease Wrap Up Flashcards Preview

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Flashcards in SA surgery and nasal disease Wrap Up Deck (30)
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1
Q

What is Sturtor?

A

reverberate soft palate, like a snore

2
Q

What is Stridor?

A

obstruction in the larynx or cranial trachea, like laryngeal paralysis

3
Q

What is Reverse sneezing?

A

often describe it wrong by owners, reflex produced to clear nasopharynx if FB in it, nasopharyngitis, dogs and cats have reverse sneeze, head often extended, on all fours and can go cyanotic, owners difficulty to describe this, like snorting for phlegm?

When v bad, need to anaesthetise otherwise will faint due to lack of oxygen and do not want it to become cyanotic

4
Q

What are some primary problems that can cause and associated with nasal disease?

A
  1. Stenotic external nares
  2. Relative overlength and hypertrophy of the soft palate
  3. Relative oversize of the tongue
  4. Tracheal hypoplasia/stenosis
  5. Sliding hiatal hernia
5
Q

What are some secondary problems associated with nasal disease?

A
  1. Tonsillar hypertrophy
  2. Everted laryngeal ventricles/saccules
  3. Laryngeal collapse
  4. Pharyngeal collapse
  5. Glosso-epiglottic mucosa displacement
  6. Scrolling of epiglottic cartilage
  7. Vomiting/regurgitation
6
Q

Pathophysiology tracheal hypoplasia?

A
  • If we can, x-ray the case: two lateral inflated films
  • Look for concurrent airway dz i.e. aspiration pneumonia
  • This x=ray- very small narrow tracheal, congenital hypoplasia as part of BOAS
  • Cannot surgically manage this
7
Q

Discuss stages of laryngeal collapse?

A
  • Stage 1 - laryngeal saccule eversion
  • Stage 2 - medial deviation of the cuneiform cartilage and aryepiglottic fold or aryepiglottic collapse
  • Stage 3 - medial deviation of the corniculate process of the arytenoid cartilages or corniculate collapse

Can get collapse of artenoid cartilage (stage 2)

8
Q

Discuss external nasal aperture stenosis?

A
  • Brachycephalic cats, get stenotic nares too
  • Stenosis of the external aperture of nose
  • Undergo rhinoplasty by doing wedge-resection
  • This is the first point of stenosis: external nares. Significant point of airway obstruction so is important surgical procedure

Rhinoplasty- wedge-resection:

9
Q

Discuss soft palate surgery techniques?

A

Surgery of soft palate: staphylectomy: à

  • Soft palate resection
  • Through mouth, dog positioned so get access to back of throat
  • Trim to level of tonsils at crypts
  • More common surgery of the two

OR soft palate palatoplasty –> (second)

  • Surgeon discretion
  • Taking thickness out palate and shortening at same time
  • Incise palate, roll forward and cut muscle layer out
10
Q

Discuss tonsillectomy?

A

Tonsillectomy: ‘meat in the box’

  • The more meat you can remove, the better the afterwards
  • Tonsils enlarged and in the way, can be removed easily to improve size of airway
  • Not everyone does this
11
Q

Discuss Idiopathic acquired laryngeal paralysis?

A
  • Stridor common presentation
    • Definition is Noise on inspiration
  • But dog in video had: Noise on inspiration and expiration
    • When obstruction so severe, can get expiratory noise- common with laryngeal paralysis
    • Pathognomonic

Horses tend to get unilateral hemiplasia, they tend to get a left sided laryngeal paralysis as longest laryngeal nerve, dogs however, get idiopathic bilateral laryngeal paralysis (both cartilages paralysed).

12
Q

Discuss arytenoid movement?

A
  • Inspiration – cartilages are abducted
  • Expiration – cartilages are adducted (air break)
  • Expiration at exercise – cartilages are abducted
  • Size of the rima glottidis is determined by the respiratory needs of the animal

Degree of abduction – depends on how much air flow required (exercise etc.)

13
Q

What is the aetiology of laryngeal paralysis?

A

Aetiology exact aetiology remains unclear

  • Neurogenic atrophy of the intrinsic laryngeal muscles
  • Dysfunction of the recurrent laryngeal nerves
  • Generalised peripheral neuropathy involving long and large diameter nerve fibres
  • Central nervous system origin
  • Hypothyroidism (?)

The dz in the dog, is most commonly presented as idiopathic dz.

Often older aged dogs in large breeds – i.e. 12y/o Labrador retriever

14
Q

Clinical signs of laryngeal paralysis?

A

Clinical signs:

  • Stridor
  • Cough
  • Dyspnoea
  • Change in phonation (bark)
  • Exercise intolerance
  • Collapse
  • Signs are related to the severity of the paralysis present
  • Most dogs present late in the course of the disease
  • Clinical signs worse when the dog is hot, excited and exercised
  • Anything putting resp rate up will make them worse i.e. stress, temperature, exercise, excited
15
Q

Diagnosis of laryngeal paralysis?

A

Characteristic clinical signs

  • Auscultation of the larynx and the thorax
  • Laryngoscopy (under a light plane of general anaesthesia)
  • Straight-bladed laryngoscope (Miller)
  • With laryngoscopy
  • Propofol anaesthesia
  • Using laryngoscope
  • Looking to see movement of aretnoid cartilage
  • If over anaesthetise, obliterate artenoid movement
    • The animal should be just about swallowing
  • As air flows through larynx, drop in pressure, draw aretenoid cartilages together and may get paradoxical movement as may mistake this for noimral movement
  • Common dog/animal has neurological signs alongside: dysphagia, dysfunction and HL dz

Diagnosis cont’d:

  • Survey inflated radiographs of the thorax
  • Neurological examination
  • Routine haematology and blood biochemistries
  • Thyroid function testing?
  • Concurrent disease:
    • Cardiac
    • Lower respiratory tract
    • Dysphagia
    • Megaoesophagus
    • hypothyroidism
16
Q

Discuss emergency medical treatment for laryngeal paralysis?

A
  • Dog often hyperthermic as cannot regulate temperature
    • Fan, surgical spirit (peripheral cooling vs systemic cooling?), wet towels
  • Sedation? (ACP may make it worse, dog may become more wound up and anxious)
  • Rest (calm – both dog and owner)
  • Supplemental oxygen
  • Cooling
  • Sedation
  • Intravenous access
  • Intravenous corticosteroids (?)
  • Anaesthetise => tracheostomy tube placement (?)
17
Q

Discuss Surgical management- arytenoid lateralisation (tieback)?

A
  • Aims to widen the rima glottdis and prevent dynamic collapse of the arytenoid cartilage
  • Almost invariably performed as unilateral procedure
  • Open the rumiglottis, make it wider and stabilise the unstable arytenoid
  • On dog, only usually operate on one side
    • Side picked often depends on whether surgeon right or left handed
    • i.e. right handed may find easier for surgery on right side
    • Do not do both sides, huge risk of aspiration pneumonia
  • Arytenoid is caudalised and lateralised
    • Cartilage can no longer adduct
18
Q

Discuss the Post-operative care/period for arytenoid lateralisation (tieback)?

A

Post-operative care/period

  • Observe feeding and drinking
  • Strict rest for 2-3 weeks
  • Antibiotics
  • Analgesics
  • Harness

Complications

  • Seroma formation
  • Aspiration pneumonia
  • Inadequate lateralisation
  • Suture failure/recurrence
  • Change in bark
  • In the right hands, surgical outcome is general very good
  • Aspiration pneumonia: taken away some protective function of larynx
19
Q

Describe tracheal collapse?

A
  • Generally refers to condition of excessive collapsibility of the trachea which usually results in dorsoventral flattening of the tracheal lumen
    • Think small Yorkshire terrier type
    • Think small dogs
  • Often congenital nature to it
    • Has an adult acquired onset time frame
20
Q

What are the Conventional survey radiographs for suspected tracheal collapse?

A

Conventional survey radiographs

  • Include neck in radiography
  • Lost tracheal shadow as trachea has collapsed
  • Commonly affects towards the thoracic inlet:

Diagnostic: endoscopy

  • Looking to see collapse and severity of collapse
21
Q

How does tracheal collapse appears on endoscopy?

A
22
Q

What is medical management for tracheal collapse?

A

Medical management:

  • Antitussives
  • Bronchodilators
  • Antibiotics
  • NSAIDS
  • Corticosteroids (inhaled)
  • Bronchodilators (inhaled)
    • Often compromiosed mucociliary escalator
    • Inhaled: more targeted
23
Q

What is the surgical management of tracheal collapse?

A

Surgery: open ring prosthesis

  • Put a number of ridged plastic rings externally/extralumial and force trachea back into normal shape with the rings round it
  • Easier for cervical region

Stenting surgery:

  • Self expanded stents
  • Intra-luminal stent
  • Expands to fill whatever lumen you put it into

Complications:

Chronic cough because stent doesn’t sit well in mucosa

24
Q

Discuss nasal disease in dogs?

A
  • FB
    • Not that common
  • Tumour
    • More common
  • Aspergillosis
  • Chronic rhinitis
  • Dental disease?
  • “Allergic”
  • Epistaxis
  • Nasal disease
  • Coagulopathy
  • Aspergillosis: fungal – common?
  • Epistaxis: nose bleeds, often tumours and fungal rhinitis or lungworm or coagulopathy
  • Investigation very similar to each case: depends on money of owners
    • CT often first not rhinoscopy
  • Plain radiography not often rewarding, same as rhinoscopy

Investigation

  • CT scan
  • Rhinoscopy
  • Radiography
  • Nasal flush
25
Q

Discuss chronic rhinitis in cats?

A
  • Common cause of chronic nasal discharge in cats.
  • Inflammation and swelling of the conchae; there is increased mucus production and usually secondary infection, mucopurulent secretion may contain blood.
  • In some cats the inflammation continues and becomes more severe, resulting in loss of conchae.
  • This can be mild or severe.
  • Cats with chronic destructive rhinitis look similar endoscopically to dogs with aspergillosis of the nasal passages.
  • It has been suggested that feline herpesvirus 1 could play a role in chronic nasal inflammation, resulting in destructive rhinitis (Johnson and Maggs 2005).
  • Hard to diagnose and treat
26
Q

Discuss fungal rhinitis (aspergillosis)?

A
  • Mainly seen in dogs
  • Rarely in cats
  • Sinonasal aspergillosis
  • Common cause of nasal Dx
  • Less common than neoplasia
  • Medium to long nosed breeds
  • More common in dogs cf. cats
  • Most cases seen is due to aspergillosis
  • Mucopurulent, snotty discharge, often UNILATERAL, may have some blood or haemorrhage or intermittent epistaxis
  • Can affect nasal cavity or can for into frontal sinus, very destructive
  • ZOONOTIC potential
    • Pregnant women, immunocompromised, chemo therapy
27
Q

Fungal rhinitis continued?

Where is it restricted to?

Where does it destruct?

A
  • A fumigatus
  • Disease generally restricted to nasal cavity and sinuses
  • But is markedly destructive to turbinates
  • Can erode frontal bones and cribriform plate
28
Q

Clinical signs of aspergillosis?

A
  • Nasal discharge
  • Mucopurulent
  • Unilateral à bilateral
  • Intermittent epistaxis
  • Ulceration or depigmentation of nasal planum
  • Pain on palpation
  • Sneezing
  • Facial deformity?
  • Neurological signs?
  • More commonly to be unilateral
29
Q

Diagnosis and tests for aspergillosis?

A
  • History, clinical signs
  • Blood tests?
  • r/o coagulopathy
  • Coagulation profile
  • Diagnostic imaging
  • Radiography of nose and sinuses
  • CT/MRI
  • Rhinoscopy
  • Rigid endoscope
  • Flexible endoscope (anterograde sinuscopy)
  • Guided biopsy
  • Cytology
  • Serology?
  • Negative serology for aspergillosis – cannot rule out aspergillosis
  • If positive, also not diagnostic as may have just been exposed
  • Often CT then rhinoscopy to see the plaques – looks like stale mouldy toast?
  • Best diagnosis is to see organisms or culture them
30
Q

What is the treatment for aspergillosis?

A
  • Challenging to treat
  • Oral antifungal agents (‘azoles)
    • Requires prolonged treatment
    • Side effects (anorexia, V+) common
    • Not recommended
  • Topical therapy
    • Preferred option
    • enilconazole, clotrimazole
  • Choice of delivery method?
    • Catheter placement in frontal sinuses via surgery (~ 80% success – treat 7 -14 d bid)
    • Minimally invasive methods
    • Use of debridement
  • Anti-fungal
    • Delivered systemically – not common as some can be toxic – hepatotoxicity
    • So topically – but needs to get to the site
    • Remove the plaque with endoscope (at time of scope)
    • Then treat with topical anti-fungal agent
  • Tube into frontal sinus
  • Remove plaque then treat dog with anti-fungal treatment more than once is best effective
  • OR single treatment, via catheter, into nose, antifungal agent
    • Not as effective as treatment above with frequent flushing
  • Minimally invasive techniques
  • Infusion of nasal cavities under GA
  • Success rate

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